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| Title |
Utilizing a Microsurgical Approach for Periodontal Surgical Procedures Can Lead to Improved Clinical and Patient Reported Outcomes |
| Clinical Question |
In patients undergoing periodontal surgical procedures, does the use of a microsurgical approach compared to conventional approach result in improved clinical outcomes? |
| Clinical Bottom Line |
A microsurgical approach (using an operating microscope [OM] or high-power loupes) can lead to significantly improved early soft tissue healing, probability of achieving complete root coverage, granulation tissue removal, and patient-reported outcomes like reduced post-operative pain and improved esthetics compared to the conventional approach. However, there was no significant difference in healing outcomes for crestal bone quality, free gingival graft shrinkage, or keratinized gingiva width gain for the procedures investigated. The benefits of microsurgery should be weighed against the longer operative time and the need for specialized equipment and training. |
| Best Evidence |
(you may view more info by clicking on the PubMed ID link) |
| PubMed ID |
Author / Year |
Patient Group |
Study type
(level of evidence) |
| #1) 33928441 | Di Gianfilippo 2021 | 510 patients with 614 gingival recessions in 19 prospective clinical trials (9 comparative trials included in meta-analysis) | Systematic Review and Meta-Analysis | | Key results | Microsurgery (OM or loupes) yielded 6.64% higher mean root coverage (p<0.001) and a 27.9% increase in the probability of complete root coverage (cRC) (p<0.01). Compared to control, OM use resulted in a 6.7% higher mean root coverage (p=0.002) and a 31.05% increase in cRC (p=0.001). Microsurgery reduced postoperative pain at days 3 and 7 (p<0.001) and enhanced esthetics (p=0.05). The mean duration of the procedure was 11.7 minutes longer in the microsurgery group compared to control (p<0.001). | | #2) 39403776 | Sirinirund 2025 | 40 non-molar teeth in 33 patients requiring extraction and Alveolar Ridge Preservation (ARP) | Randomized Controlled Trial | | Key results | The OM group had significantly fewer sites with granulomatous tissue remnants after socket debridement (p=0.01) and a better healing score at 2-week (p=0.04) and 4-week (p=0.01) time points. However, there were no significant differences in 12-week crestal bone healing (histology, US, or CBCT) or Patient-Reported Outcome Measures (PROMs) (p>0.1). | | #3) 40713690 | Aslroosta 2025 | 22 patients requiring Free Gingival Graft (FGG) for gingival augmentation (11 in each group) | Randomized Controlled Trial | | Key results | The primary outcome, FGG graft shrinkage at 3 months, was not statistically different between the groups (p>0.05). The microsurgery group displayed significantly better color match at 3 months (p=0.04), faster early healing at 2 weeks (p=0.009), and lower post operative pain (first week, p=0.04) and edema (days 4-5, p<0.05). The microsurgery group required significantly more operating time, nearly 23 minutes (mean 100.82±19.11 min vs 78.09±3.67 min; p=0.003). | | #4) 33928441 | Sabri 2024 | 55 human clinical studies using an Operating Microscope (OM) | Systematic Review | | Key results | Microsurgery under an OM enhances wound stability and accelerates healing due to more delicate tissue manipulation and improved flap refinement. OM use is effective in periodontal plastic surgery (mainly root coverage) and periodontal regeneration (via guided tissue regeneration). OM use can also be beneficial for sinus floor elevation to prevent and manage membrane perforations. However, high risk of bias and data heterogeneity largely precluded quantitative analysis. | |
| Evidence Search |
(microsurgery or microscope) and periodontal outcomes
(periodontal microsurgery outcomes) NOT (endodontic microsurgery) |
Comments on
The Evidence |
The CASP appraisal was used to aid in confirming validity to support the conclusion that the microsurgical approach provides clinical benefits at the expense of increased surgery time. Baseline characteristics were relatively similar among comparison groups in these articles. However, magnification level was consistently inconsistent, introducing heterogeneity. Due to the intervention type, operator blinding was not possible in the surgical procedures. Di Gianfilippo 2021 employed a comprehensive search strategy of three databases (MEDLINE/PubMed, Embase, and CINAHL). Quality was reviewed using Cochrane Collaboration tool and Joanna Briggs Institute Critical Appraisal tool. The authors noted the heterogeneity of some data, particularly magnification level and treatment modalities for root coverage (with or without a connective tissue graft). Increased procedure duration was given in minutes without a percentage of time increase (or total time means like Alsroosta) which makes it harder to determine the significance of the time increase. The two RCTs, Sirinirund 2025 and Aslroosta 2025, minimized bias by using a randomized allocation and blinding the outcome examiners, ensuring the baseline groups were comparable and that outcome measurements were sound. Although not statistically significant, there was a larger number of females in the Alroosta study. Attrition was minimal in both studies, with 1/40 in Sirinirund and 2/24 in Alroosta lost to follow up. In all articles, follow up did not exceed 2 years and generally were 6 mo. or less. Sabri 2024 searched Pubmed, EMBASE and SCOPUS, for articles that looked at periodontal treatment outcomes for a wide variety of procedure types including regeneration, root coverage, implants, and orthodontic-periodontic surgeries in addition to others. The article was limited to qualitative synthesis due to high heterogeneity and high risk of bias in over half of the studies included. Authors advised “interpreting cautiously,” suggesting usefulness in formulating initial ideas which can be validated by other research. The authors also note the limitation of relatively low numbers of studies directly comparing OM to conventional macrosurgery. |
| Applicability |
The findings are applicable to patients undergoing various types of periodontal surgeries, particularly mucogingival (Di Ginafilippo: root coverage by apically positioned flaps with or without CTG, and Alsroosta: FGG to increase keratinized gingiva), which can directly benefit from the enhanced soft tissue management that microsurgery provides. The patient populations studied typically were comprised of middle-aged adults (mean age reported ranging from about 43 to 66 depending on study) requiring treatment for localized gingival recession or bone augmentation (Sirinirund: alveolar ridge preservation of premolar sites), making the results generalizable to periodontists and other providers performing these procedures. However, limitations do apply, particularly in patients with conditions that may alter healing processes, as they were not included in these studies. The studies highlighted that the major limiting factors are the longer procedure time and the high cost and learning curve associated with acquiring and mastering the operating microscope and microsurgery instruments. The benefits of improved early healing, esthetics and reduced early postoperative morbidity (pain and edema) must be weighed. |
| Specialty/Discipline |
(Periodontics) |
| Keywords |
microsurgical approach, microsurgery, operating microscope, periodontal, surgery, outcomes
|
| ID# |
3586 |
| Date of submission: |
10/13/2025 |
| E-mail |
allens1@uthscsa.edu |
| Author |
Samuel Allen |
| Co-author(s) |
Tyler Stevens |
| Co-author(s) e-mail |
stevenst4@uthscsa.edu |
| Faculty mentor/Co-author |
Angela Palaiologou Gallis |
| Faculty mentor/Co-author e-mail |
palaiologoua@uthscsa.edu |
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) |
post a rationale |
| None available | |
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Comments and Evidence-Based Updates on the CAT
(FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) |
post a comment |
| None available | |
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